Fillable Form E-111: Renewal Application for Life and Health (Arizona)

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Form E-111: Renewal Application for Life and Health (Arizona)

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Form E-111 (v 20201031)
Email: TPAinformation@difi.az.gov
Form E-111: Renewal Application for Life and Health Administrator Registration
SECTION A: Applicant Identity
Department Use:
A business entity applicant must be organized in good standing with the appropriate
government agency. Update outdated information with the other government agency before
submitting this application to the Dept. of Insurance and Financial Institutions. ARS §§ 20-485.12(B)(2), 20-485.12(F).
Applicant Name:
FEIN #:
DBA Name (if applicable):
State Incorporated/Organized:
Type of Entity: Corporation LLC Trust General Partnership Limited Partnership
Sole Proprietorship Other ______________________________________________________
SECTION B: Contact Information
Mailing Address:
City:
State:
ZIP Code:
Main Administrative Office Address:
City:
State:
ZIP Code:
Area Code and Phone Number:
Fax Number:
Contact Person – Name:
E-mail Address:
Title:
Phone Number:
SECTION C: Summary of Financial Position. Provide the following information from the financial
statements included with this application (see Section E, Item 4):
1.
(INCOME STATEMENT)
Net Income
2.
(BALANCE SHEET)
Current Assets
3.
(BALANCE SHEET)
Current Liabilities
4.
(BALANCE SHEET)
Working Capital
5.
(BALANCE SHEET)
Owner’s Equity
6a. Arizona charges and/or premiums
collected for an insurer* in the
preceding calendar year, or if no
premiums were collected during the
preceding calendar year, the amount
reasonably estimated to be collected
during the current calendar year:
6b. Arizona claims paid for an
insurer* in the preceding calendar
year, or if no claims were paid during
the preceding calendar year, the
amount reasonably estimated to be
paid during the current calendar year:
6c. Total funds handled for an
insurer* during the preceding
calendar year, or if no money was
handled during the preceding
calendar year, the amount reasonably
estimated to be handled during the
current calendar year: (6a + 6b):
*”For an insurer” means charges and/or premiums collected for or claims paid for an insurer. It excludes funds handled directly for employers or
employer trusts.
7. Additional financial position requirements (if this space is not blank):
A response to Section C, Item 1, 4 or 5 was negative. You must ENCLOSE a description of the applicant’s plan to
become financially solvent, such as capital infusion, parental guarantees, etc. For plans that involve a third party,
ENCLOSE a letter from the third party that describes the investments or guarantees the third party is providing to the
applicant, and ENCLOSE financial statements (balance sheet and income statement) of the third party.
IMPORTANT!
0
0
Reset
Applicant Name:
PAGE 2 of 3
Form E-111: Renewal Application for Life and Health Administrator Registration (v 20201031)
APPLICANT DOES NOT QUALIFY FOR THE LICENSE. The applicant/employee is not
permitted to have this type of an ownership interest pursuant to ARS § 20-485.11(C).
SECTION D: Applicant Declaration (ARS § 20-485.12(B)(7))
YES (x) NO (x)
1. Did the applicant have an insurance license of any kind that was refused, suspended or
revoked in Arizona or in any other jurisdiction? If YES, see Section E, Item 15.
2. Has the applicant been indebted to any person?
3. Has the applicant had any administrative agreement canceled? If YES, see Section E, Item 15.
SECTION E: Required Enclosures
1. ENCLOSE payment of the $195 fee, made payable to Arizona Dept. of Insurance and Financial Institutions
2. SATISFY the deposit requirement.
a. Enter the amount of the deposit (surety bond, certificate of deposit or marketable
security) that the administrator submitted to the Arizona Department of Insurance
and Financial Institutions and that is currently in force and held in trust for the benefit
and protection of insureds and insurers whose monies the administrator handles.
b. Based on the information entered in Section C, Item 6c, the minimum deposit that the
administrator must maintain per ARS 20-485.10.
Because the required deposit exceeds the deposit you currently have on file, you must either replace the existing
deposit or submit an additional deposit so that the total deposit in force is no less than <Amount-§E.2b>.
ENCLOSE the replacement or additional deposit in favor of the state by ONE of the following methods:
a. Surety bond: Must be issued by an insurer authorized in Arizona to offer surety bonds; may include individual
bonds, schedule or blanket bonds. You cannot use an existing fidelity or liability policy to satisfy this
requirement. ENCLOSE Form E-157 and an Attorney-in-Fact.
b. Certificate of deposit (CD): ENCLOSE one E-125-CD form, two E-150 forms, and the original of the CD.
c. Marketable security: ENCLOSE one Custody Agreement (Form E-003) and one Form E-125.
3. Does the applicant use any name or have any office other than those previously reported to the Arizona
Department of Insurance and Financial Institutions?
YES. ENCLOSE Form E-100-A to report the applicant’s complete name and address for all offices in each
jurisdiction (ARS § 20-485.12(B)(6)).
NO. You do not need to complete Form E-100-A.
4. ENCLOSE a nonconsolidated GAAP income statement and GAAP balance sheet for the period ending
December 31 of the preceding calendar year, verified by two officers of the applicant. ARS § 20-485.12(E)
Section E, Items 5 through 8 are purposely omitted.
9. Does the applicant or any employee of the applicant directly, or through control of any other person, have
an ownership interest in any insurer except as a shareholder of less than 1% of the shares of any publicly
owned insurer? ARS § 20-485.11(C)
YES NO
10. Is the applicant owned by another entity that directly or indirectly controls the applicant?
ARS § 20-485.12(B)(3)
YES NO
11. Does the applicant directly or indirectly control any affiliate entity? ARS § 20-485.12(B)(3)
YES NO
You answered “YES” to Item 10 or Item11, ENCLOSE a holding company system chart that shows the
parent/child/sibling relationships among each holding company system member, including each affiliate that directly or
indirectly controls the applicant and every affiliate the applicant directly or indirectly controls. ARS § 20-485(B)(3)
Pay the $195 fee using the TPA Portal
5,000
5,000
Applicant Name:
PAGE 3 of 3
Form E-111: Renewal Application for Life and Health Administrator Registration (v 20201031)
Section E, Item 12 is purposely omitted.
13. ENCLOSE Form E-100-B to report the name and title of each “individual responsible for the administrator’s affairs”
for whom an NAIC Biographical Affidavit Form 11 was not previously submitted to the Arizona Department of
Insurance and Financial Institutions by the applicant. If biographical affidavits were previously submitted for all
individuals responsible for the administrator’s affairs, enclose Form E-100-B and enter “NONE” for the first item in
Section B.
“Individuals responsible for the administrator’s affairs” include:
• All members of the board of directors/trustees, members of the executive committee or any other governing
board of the committee, PLUS
• If applicant is a corporation, all officers and all shareholders that directly or indirectly hold at least 10% of the
voting securities of the applicant if a corporation, AND
• If applicant is a partnership or association, all partners.
ENCLOSE an NAIC Biographical Affidavit Form 11 for each individual listed on Form E-100-B.
ARS § 20-485.12(B)(5).
IMPORTANT! The Department will investigate information provided and may deny a license if the applicant fails to
provide complete and truthful information about itself and the individuals responsible for the administrator’s affairs.
14. Did any NAIC Biographical Affidavit Form 11 submitted with this application contain a “Yes” response to
one or more question in Item 11? ARS § 20-485.12(B)(5)
YES. ENCLOSE a copy of the complaint and the filed adjudication or settlement for each matter.
NO.
15. OTHER REQUIRED ENCLOSURES based on responses in other parts of this application form:
You responded YES to Section D, Item 1 or 3. You must ENCLOSE a signed statement detailing all incidents including
names of all parties involved, dates and locations, the names and localities of any courts and administrative agencies
involved, the disposition of each matter, whether the conviction, plea or finding was for a felony or open-ended charge;
AND, you must ENCLOSE copies of any and all indictments, complaints, plea agreements, orders of conviction, notices
of hearing or trial, sentencing orders, suspension/revocation orders and any other information that relates to each
matter. If copies are not available, you must provide as a part of this application a letter from the clerk of the pertinent
court or the official involved stating the records are not available and the reason.
SECTION F: ATTESTATION (must be signed by two officers of the administrator)
All of the information contained in this application, including but not limited to the annual financial statement and all other
enclosures and attachments, are true and correct to the best of our knowledge and belief.
_______________________________________ _____________________________ ________________
Signature Printed Name Date
_______________________________________ _____________________________ ________________
Signature Printed Name Date
ARS § 41-1030(G) requires most Arizona government agencies to prominently print the provisions of ARS § 41-1030(B), (D), (E) and (F) on
all license applications. The following is the language in ARS § 41-1030(B), (D), (E) and (F): B. An agency shall not base a licensing decision in
whole or in part on a licensing requirement or condition that is not specifically authorized by statute, rule or state tribal gaming compact. A general
grant of authority in statute does not constitute a basis for imposing a licensing requirement or condition unless a rule is made pursuant to that general
grant of authority that specifically authorizes the requirement or condition. D. This section may be enforced in a private civil action and relief may
be awarded against the state. The court may award reasonable attorney fees, damages and all fees associated with the license application to a party
that prevails in an action against the state for a violation of this section. E. A state employee may not intentionally or knowingly violate this section.
A violation of this section is cause for disciplinary action or dismissal pursuant to the agency’s adopted personnel policy. F. This section does not
abrogate the immunity provided by section 12-820.01 or 12-820.02.
Submit the application, enclosures, and fee using the TPA Portal
(https://azinsurance.online/Upload/tpa
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Form E-111: Renewal Application for Life and Health (Arizona)

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Completed 1 July 2022

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